Study Day 2019

23rd March

SAAD Editorial Board

SAAD Membership

Membership of SAAD is open to any registered medical or dental practitioner or dental nurse whether based in the UK or abroad. Student membership of SAAD is free for dental and medical undergraduates registered at a university in the UK or Ireland.

SAAD Assessed Sedation Nurse Course

History

The Beginning

In the early 1930's Stanley Drummond Jackson was a dentist practising in Yorkshire. He was the son of a dentist. In those days dentists largely employed general medical practitioners to provide nitrous oxide based anaesthesia for their patients. Generations of children grew up to know the dread of "gas" at the dentists... As a young dentist Drummond Jackson or ‘DJ' as he became known later, was appalled at the inadequacy and poor quality of general anaesthetic provision for dentistry. In a way that would now be considered totally unacceptable but was then completely permissible, Drummond Jackson experimented with new intravenous anaesthetic drugs introduced from Germany and America. By trial and error he developed a method of intravenous anaesthesia that worked providing fast onset, variable operating time and quick recovery. DJ was enthusiastic about his technique and over the next seven years he recorded over 8000 successful cases. The Second World War intervened. Afterwards DJ set up a practice at 53 Wimpole Street, London and continued his use of intravenous anaesthesia. He ran a thriving practice and caught not only the attention of patients wanting oblivion for their dentistry, but also the attention of a group of fascinated medical and dental practitioners. One of these was Dr Henry Mandiwall, a consultant oral surgeon and also an accomplished film maker. Together they made a film on venepuncture techniques for general practice. This film was accepted by the British Medical Association and became the first of a series of films detailing DJ's intravenous technique adopted by various teaching bodies.

In 1955 DJ started a study club which rapidly grew in size and by 1957 the Society for the Advancement of Anaesthesia in Dentistry was born. It was fortuitous that from the start SAAD attracted the interest of the great and the good. The Society's Trust Deed was drawn up by the Lord Chancellor of England and a future eminent professor of anaesthesia, Robert MacIntosh (later Professor Sir Robert MacIntosh), attended meetings because at the time he was providing anaesthesia for dentistry at a dental practice in Mayfair. Although pursuing a fellowship in surgery MacIntosh needed the money dental anaesthesia brought in. Unwittingly SAAD was to become a catalyst in the academic and clinical development of anaesthesia in the UK. MacIntosh gave an anaesthetic in the Mayfair dental practice to Sir William Morris (of motor car fame).

Sir William Morris had previously had an unpleasant anaesthetic experience but MacIntosh's intravenous dental anaesthetic had changed his view. Morris and MacIntosh became friends and subsequently Morris told MacIntosh that Oxford University had approached him with a plan to endow chairs in medicine, surgery and midwifery. MacIntosh persuaded Sir William Morris that to endow a chair in anaesthesia would be both innovative and extraordinary. Ultimately Sir William offered Oxford University, four Chairs including anaesthesia and funding of £1 million. Opposed to the anaesthetic chair, Oxford University declined so Sir William offered the university £2 million to include anaesthesia on a take-it or leave-it basis. Unable to resist such a magnificent offer, Oxford University established the first department of anaesthetics in Europe. Sir Robert MacIntosh became the first Professor of Anaesthesia in Europe and Sir William Morris became Lord Nuffield.

Christopher Holden August 2008, President of SAAD

A Scientific Basis

From the very first meeting in 1957, SAAD was heavily involved in the use of intravenous anaesthesia and from the beginning it had close associations with Guy's Hospital, London which continued unabated. SAAD's first President was Mr Alan Thompson, a consultant oral surgeon at Guy's. Early meetings explored the challenges of barbiturate dosage, laryngeal spasm, aspiration and the supine position for anaesthesia. From the outset SAAD's attitude was clear. The Society had a policy of embracing a range of anaesthetic techniques and also formally disapproved of the dental operator also being the anaesthetist. It was agreed that patient welfare was paramount. By today's standards, mortality was high with intravenous barbiturates and with these new techniques some career anaesthetists were concerned about selecting the right people to teach how to administer them whether they were doctors or dentists. In the late 1950's it was clear to some that SAAD led the way in the future of intravenous anaesthesia in general and for dentistry in particular at a time when the intravenous route was a minority practice and total intravenous anaesthesia was rare.. Meetings were led by Dr John Buxton, a consultant anaesthetist at Guy's Hospital; Dr Morris Hudson, a consultant anaesthetist at University College Hospital; and Dr James Bourne, a consultant anaesthetist at St. Thomas' Hospital, amongst others. Meetings embraced such topics as safety, the causes of syncope and also success stories. SAAD grew rapidly as did the practice of intravenous anaesthesia in dentistry. By 1967 membership was 2000 and 10% of dental practices in the UK provided intravenous anaesthesia. This rapid spread led to alarm by an increasing number of dentists and anaesthetists.

Early Teaching

In 1959 a series of three day courses were held on general anaesthesia in dentistry. Each course was limited to eight people and took place in the basement of 53 Wimpole Street. The first two days were didactic teaching and the third day was devoted to clinical demonstrations. As the number of course registrants grew the number of courses went up to eight a year with 24 practitioners on each. Logistically it became difficult to provide hands on training on an individual basis and practical emphasis was SAAD's modus operandi. This resulted in the development of "table demonstrations" a precursor to the modern rotating seminars which SAAD still offers today.

The development of teaching from the beginning to our modern society today traces a record of the challenges of teaching large numbers new clinical skills and the provision of safe and comfortable care for patients in constantly changing political circumstances. Some doctors and dentists openly disapproved of SAAD's initiative. The Society has never avoided the tensions and professional differences between these doctors and dentists over who should give what to whom, where and when. The divisions between the professions came to a head when the British Medical Journal published a paper in 1969 on intravenous methohexitone in which the authors castigated Drummond Jackson and his technique. The technique the authors of the paper had used in their research (which was not that technique promulgated by SAAD) was condemned by their conclusions. DJ asked the British Medical Journal to publish a statement of withdrawal. This did not occur so he sued for libel. The legal case became the longest libel action in British legal history. The case was never completed as the judge recommended each party admonish the other for all blame and agree to disagree.

Thereafter it was clear to all that doctors and dentists had to co-operate and collaborate in the provision of pain and anxiety control for dental patients but it took a generation to heal the wounds and both professions viewed each other with some suspicion. Thankfully for SAAD, there were dentists and anaesthetists who saw beyond this narrow issue and Dr Thomas Boulton a consultant anaesthetist from Oxford and Reading and soon after President of The Association of Anaesthetists drew the professions together during his presidency of SAAD in 1980. At that time some universities were providing a group of young dentists with formal training in general anaesthesia for dentistry during a full time postgraduate course. Most of these joined SAAD and lacking the baggage of recent history began to renew progress. After the legal case the Society continued to develop by insisting on academic competence, clinical excellence and appropriate training pathways. The Society flourished developing mass training in the so called ‘Jumbo Courses' where up to 240 participants were taught together at University College London.

Modern Teaching

In the 1980's the mainstay of SAAD's training remained two or three day courses with a large practical element. This became known as the "Main Course". During this time SAAD courses moved between the Eastman Dental Hospital, the Whittington Hospital and the Royal Free Hospital at Hampstead, all necessitated by fluctuating numbers of course participants. By 1987 Dr Ian Brett recognised the need for training of dental nurses and their own dedicated course. To this day both the nurses' course and the dentists' course run in parallel. For a time the main course moved to the practice of Dr Peter Hunter, a forward thinking Australian dentist whose practice was technologically advanced in equipment ergonomics and early computerisation. The facilities necessitated a rotation of small groups experiencing up to eight clinical cases a session. Peter Hunter quickly realised the benefits of this style of training and decided to develop SAAD's seminars. The early 1980s were financially difficult for the Society and without a new and firm treasurer in Dr Ian Brett SAAD may well not have survived. By 1984 SAAD had ceased to teach general anaesthesia and focused on conscious sedation and Life Support. The course organisers during this time included Dr Brian Swinn and Dr Douglas Stewart who later emigrated to Australia to become an associate professor in dental sedation. Following a move to St Bartholomew's Hospital in London, SAAD courses settled there for the next decade, With Peter Hunter's enthusiasm and organisational skills SAAD was one of the first professional groups to develop the "travelling road show" where a diverse group of experts would travel the country to provide the same programme in one or two days. The format was short, punchy lectures followed by rotating practical seminars. SAAD Seminars offered seminars on sedation, monitoring, Basic Life Support and Advanced Life Support. SAAD led the way in the late 1980's and early 1990's with resuscitation training for dentists. This was enthusiastically supported by Dr Peter Baskett who taught on the seminars and who became President of The Association of Anaesthetists of Great Britain and Ireland. The Life Saver seminars were so successful that the format of Life Saver 1 and Life Saver 2 was exported in its entirety to Australia.

Annual scientific meetings complemented the courses and invariably these were held at The Royal society of Medicine London. These reflected the origins of SAAD and continued to be supported by a full audience. SAAD encouraged teamwork and dental students and dental nurses were welcomed to meetings. This was supported by SAAD offering a monetary prize for essays from both dental nurses and dental students on an annual basis. The DJ memorial essay prize which is open to all medically or dentally qualified graduates continued to be offered every year with a prize of £500.

By 1997 SAAD's teaching had transformed from a decade previously and the 40th Anniversary Programme concentrated on new sedative drugs, undergraduate teaching and the role of dental nurses. The Society was beginning to develop a more structured training. The courses were relaunched as the National Course in Conscious Sedation for Dentists and Dental Nurses. Both programmes were fully audited continuing professional education programmes offered on a national scale. The new style training and the travelling seminars overcame SAAD's financial difficulties and the society became financially secure. A number of regional ad hoc courses contributed to the centralised teaching including ‘First Response' a course on management of medical emergencies using advanced simulation techniques, led by Dr Diana Terry of the UK Resuscitation Council. Occasionally SAAD also provided short courses with a reduced faculty in a number of other countries including Germany, France, Belgium and Zimbabwe amongst others. Dental nurse training opportunities were expanded in 1999 with the addition of a second course which helped nurses to prepare for the National Examining Board for Dental Nurses' (NEBDN) Certificate in Dental Sedation Nursing. This came to be known within SAAD as the "Part 2" course. This element was developed at Guy's Hospital by Dr David Craig and Dr Carole Boyle both of whom were examiners for the NEBDN qualification. Moving to Queen Mary, University of London in 2004 the SAAD National Course had a core programme reflecting the close associations SAAD had developed with the Dental Sedation Teachers Group, the Association of Dental Anaesthetists, the Royal College of Surgeons of England, and the Royal College of Anaesthetists.

Guidance and Regulation

Since its inception SAAD had been heavily involved in deliberations about the regulation of the dental profession in general anaesthesia, conscious sedation and resuscitation. In 1971 the government proposed a ban on the operator anaesthetist in dentistry. The effect of this would have been to have abolished provision of the intermittent methohexitone technique on which SAAD's teaching was based at the time. Although not promoted by SAAD the operator anaesthetist was a necessity of the time due to the general lack of services of a separate anaesthetist in general dental practice. Patients faced being denied a safe and effective pain and anxiety control technique on the basis of prejudiced opinion in the Ministry of Health at the time. Along with the British Dental Association, SAAD took on the government. A booklet entitled "Treachery" was sent to every Member of Parliament detailing both the sacrifice of basic rights of patients and professional freedom of doctors and dentists and the potential loss of invaluable years of progress in pain control. Members of Parliament agreed - SAAD and the BDA won. Regulation of general anaesthesia had always been a big issue within the General Dental Council. Although there was little genuine experience amongst its own members, it was fortuitous that there was almost always a member of SAAD Council on the General Dental Council. This was important as regulation of anaesthesia, conscious sedation and resuscitation were always closely connected and issues on which the General Dental Council made frequent recommendations.

Successive Presidents of SAAD including Dr Gerry Holden, Dr Peter Sykes, and Lord Colwyn a Conservative peer, all contributed to maintaining a sensible but safely directed balance of opinion in relation to the regulation of pain and anxiety. Lord Colwyn provided an important link to government during a politically difficult time for anaesthesia and sedation in dentistry. The definition of conscious sedation drafted by Dr Gerry Holden for the Wylie Report in 1978 was subsequently adopted by the General Dental Council and today remains almost unchanged as the accepted definition of conscious sedation by all UK regulatory bodies.

In the 1990s a Department of Health sponsored a guidance document on anaesthesia sedation and resuscitation and published "The Poswillo Report". Dr Peter Sykes and Dr David Phillips were influential in stopping the General Dental Council's attempted knee jerk reaction when it considered banning general anaesthesia for dentistry in primary care at a stroke and almost taking conscious sedation with it. The foundations of SAAD's interest in starting to proactively develop clinical guidelines began in 1989 with the publication in early 1990 of "Guidelines For Physiological Monitoring Of Patients During General Anaesthesia Or Sedation", led by Dr Peter Cole. This document was well ahead of its time. From the early 1990s to this day SAAD has been heavily involved in the production of national guidelines, with representation on nearly every major report concerning anaesthesia, sedation and resuscitation in dentistry. Particularly active in this area was Dr David Craig, consultant and Head of Sedation and Special Care Dentistry at Guy's Hospital and Dr Christopher Holden, a general practitioner from Derbyshire.

A plethora of guidance occurred in the 1990's due to a few heavily publicised and largely unnecessary deaths associated with general anaesthesia and sedation for dentistry. SAAD was quick to realise that the profession needed a guidance document detailing expected standards but the Society also took the view that this needed to be guidance which involved all parties interested in the subject. In 2000 Dr Christopher Holden chaired an Independent Working Party which ultimately produced a report "Standards in Conscious Sedation for Dentistry" the first standards document for conscious sedation in dentistry. This was later taken forward to a further two documents by a joint committee of the Royal College of Surgeons of England and the Royal College of Anaesthetists. From this standards initiative SAAD played a key role in the production of "Conscious Sedation and the Provision of Dental Care" (Department of Health) in 2003 and "Standards in Conscious Sedation in Dentistry: Alternative Techniques in 2007" (Royal College of Surgeons of England / Royal College of Anaesthetists. At the same time Dr David Craig chaired a report for the Department of Heath/Faculty of General Dental Practice (Royal College of Surgeons of England) issuing guidelines for the appointment of dentists with special interest in conscious sedation, importantly providing quality control for NHS Primary Care services.

Professional Relations

After 1971 there was an uneasy truce between medical and dental practitioners over the fundamental concepts of what sorts of treatment patients should have, in what environment and being administered by whom. Slowly SAAD and the Association of Dental Anaesthetists began to work together. At times the Faculty of Anaesthetists of the Royal College of Surgeons (subsequently the Royal College of Anaesthetists) and the Association of Anaesthetists, made input directly or indirectly. These groups along with the Royal College of Surgeons of England began to understand SAAD's commitment to furthering pain and anxiety control for dental patients whilst furthering safety and it was understood that an evidence-based rather than a prejudice-based approach had to be embraced by all parties. In the 1990's SAAD formed close associations and had formal cross-representation with both the Association of Dental Anaesthetists and the Dental Sedation Teachers Group. It became clear to most in the medical and dental professions that SAAD was not to be ignored not just because it had a large professional membership but because it was genuinely working as a force for good practice and excellence in clinical care in line with General Dental Council recommendations.

The Society's meetings became increasingly scientific and diverse and by the 40th Anniversary in 1997 the speakers included amongst others Professor Robin Basker, a member of the General Dental Council; Dr David Craig, Guy's Hospital; and Dr Colin Poggo, a non-consultant career anaesthetist with a multitude of dental practices providing general anaesthesia and sedation. On the international front SAAD had been instrumental in the formation of IFDAS, (the International Federation of Dental Anaesthesiology Societies)..An international and European congress on pain and anxiety control in dentistry was held in Monaco arranged by an American dentist Dr Antonio Reyes-Guerra in 1976. Dr Reyes-Guerra thought that an international federation of interested societies would further patient care. He persuaded Dr Gerry Holden that SAAD should consider taking this work forward. The Society hosted SAAD 79, the second international congress devoted to pain and anxiety control in dentistry. At SAAD 79 the foundations of a formal international federation were conceived which was to be formalised in 1982 at a subsequent congress in Tokyo. IFDAS formed an important conduit for developing and sometimes even harnessing national aspirations particularly in relation to guidance and regulation. The Federation appointed as its first Secretary General, Dr Peter Sykes. IFDAS flourished and gained new membership quickly and SAAD continued to fly its flag on the international stage at each of the triennial conferences. In 2003 the UK became the first country to host the congress for a second time. The congress was held in Edinburgh where SAAD's President at the time Dr Christopher Holden (the son of Dr Gerry Holden) then became President of the International Federation.

IFDAS Edinburgh 2003 By 2000 nationally, SAAD set great store by inter-professional relations and worked particularly closely with The Dental Sedation Teachers Group to produce a range of sensible guidance documents as well as offering a forum for debate, not just within a specialist society but also within the universities of the United Kingdom. In 2003 SAAD (always a UK Registered Charity) was concerned about increasing surpluses and looked for ways to promote research within further education. It was decided to endow a SAAD Chair in anxiety and pain control for dentistry at King's College London Dental Institute. Professor Peter Milgrom an eminent paediatric practitioner from Washington was thus appointed as the first visiting professor in pain and anxiety control for dentistry in the UK.

Modern SAAD

There have been many contributors to SAAD since 1957. Most are not mentioned here not out of lack of respect or effort to record properly but all historical accounts carry some slant. Much of this history is gleaned from archived documents verbal accounts and the memories of current members and personal recollection. There have been many contributing council members, trustees, administrators and helpers as well as long suffering partners and spouses. SAAD has often been blessed with "lynch pins". Two such people are SAAD's Secretary for many years, Margaret Hughes and in today's guise, the society's Executive Secretary Fiona Trimingham. Without all these individuals the society would not be the success it is today.

The Society's membership peaked in 2004/2005, at 4225 members. The National Courses remained very popular and were always over subscribed, still being offered three times a year. The Annual General Meeting and scientific symposium was always well supported and was invariably held at the Royal Society of Medicine in London the location of many of SAAD's early meetings.

Traditionally SAAD's activities have been recorded in the society's journal, the SAAD Digest. Over the years the journal struggled to have impact as it was edited by an enthusiast or a coerced council member with courage but lacking journalistic or scientific skills. and it had to compete with a host of glossy dental journals. It became clear this was too much to expect of an individual alone. SAAD Digest was re-launched in 2006 as a well produced and relevant journal created by an editorial team. By 2006 SAAD was led by a consultant anaesthetist from Bath, Dr Diana Terry, following a series of six previous dental presidents. Over the previous four years the society had been transformed by a modernising executive board. It became a model charity run on a proper business footing, delivering training and support relevant to the needs of dental and medical practitioners providing care for the anxious and frightened dental patient. In all its history SAAD has had particular strengths. It adapts quickly to change; it is enthused by challenge and it is never fearful of making an issue of the basic rights of both the anxious and frightened patients who need our services and the professional freedom of those who provide those services for patients.

ABOUT SAAD

SAAD is at the forefront of postgraduate teaching of sedation techniques in dentistry.
The Society runs courses for the whole dental team encouraging the safe provision of conscious sedation. Other activities include providing scientific seminars, giving expert advice to other bodies including the Department of Health and the General Dental Council; providing experts for guidelines and standards documents; giving expert evidence to the courts; promoting research in the field of pain and anxiety control and providing individual support and advice to members.
Membership of the society is open to any registered dental or medical practitioner, dental nurse or dental therapist/hygienist.